Medicare Audit Denies Wheelchairs for 22 Severely Disabled Nashville Area Patients; Local Company Out $200,000

GOODLETTSVILLE, Tenn., Dec. 3, 2013 /PRNewswire-USNewswire/ -- Medicare is taking back more than $200,000 it paid for complex rehabilitation wheelchairs that were delivered to 22 severely disabled Nashville area patients, leaving a local company in the red and questioning Medicare's payment review process, says the American Association for Homecare.

Ben Shapiro, chief operating officer of Ed Medical Inc., is stunned that auditors for the Centers for Medicare & Medicaid Services (CMS) have ruled that these severely disabled patients don't qualify for the wheelchairs his company provided. Most of these patients received their wheelchairs from one to three years ago, and in several cases the patients have passed away.

According to CMS' rules, wheelchairs must be purchased by suppliers and delivered to patients before claims can be submitted for reimbursement. But, once claims are paid, CMS' out of control auditors subject suppliers to frequent audits. Bizarrely, they often apply new rules retroactively, resulting in denials of claims that were originally paid, such as in this case.

Shapiro has experienced questionable audits and denials in the past, but he said that nothing has been as inappropriate as the recent decisions on these 22 patients.

"These are not borderline cases," he said. "All of these patients are severely disabled. They badly need these wheelchairs to have any mobility or quality of life. It is disgraceful that some claim auditor is overruling a physician's order that also includes a twenty-page physical therapy evaluation performed by an independent wheelchair seating clinic. These patients have diagnoses of multiple sclerosis, muscular dystrophy, amyotrophic lateral sclerosis, quadriplegia, and paraplegia."

Under CMS regulations, suppliers can remove equipment after claims are denied, but suppliers rarely, if ever, take mobility equipment away from seniors and people living with disabilities. But Shapiro predicts there will be significant problems in the future because those patients won't be able to find companies to repair the equipment, since CMS won't pay for repairs to equipment that the agency didn't approve. "This has already happened to some of our customers," he said. "They need repairs, but Medicare won't pay for them because their wheelchairs have been denied."

Problems accessing repairs are widespread for Medicare patients, as are problems getting new home medical equipment. Across the country, prices for power wheelchairs, oxygen therapy, hospital beds, walkers, and other home medical equipment have been slashed by an average of 45 percent because the badly mismanaged Medicare bidding program established unrealistically low prices for goods and services.

"This all just makes you sick to your stomach,'' Shapiro said. "Medicare is trying to save money by depriving some of the most vulnerable people in our society of the medical equipment they need to stay at home with their families and live independently. There is something very disturbing about this approach to healthcare."

Moreover, Shapiro said, in the end the government will wind up spending more money and resources because it's not making good decisions on reimbursements. He will now file a challenge on the denied claims with an administrative law judge. The process may take several years, but in the past judges have overturned original CMS rulings in 80 to 90 percent of cases, so it's worth his time.

Many of the problems related to claim denials are rooted in the defective process used to document medical necessity for power wheelchairs, as well as the extensive audits that providers must endure. CMS has repeatedly refused requests by the industry for a more objective claim review process, and clearer documentation rules. The subjective nature of claim reviews and audits basically allow the agency to deny any claim it wants. Providers argue that CMS uses the flawed process to lower patient utilization of the mobility benefit and also lower their costs.

CMS makes ever-changing and retroactive demands that the majority of physicians say are unrealistic, and can't be met. For instance, CMS requires doctors to make handwritten progress notes in their patients' medical records. Even more problematic, CMS has created an environment in which auditors routinely overrule prescribing physicians and their clinical assessments of patients, such as in Ed Medical's case.

Across the country, thousands of claims are denied, not because of questions related to medical necessity, but because the physician documentation wasn't presented in the format that CMS desired. The rules don't allow the use of a preprinted or "check box" approach and will result in denials if used. Moreover, CMS applies a literal interpretation of the term "written prescription," suggesting that the law says a physician must "write" a prescription and have no part of the form pre-printed, such as the patient's name. Claims will be denied if the physician's signature is not legible. And finally, CMS insists that prescriptions be date-stamped with a rubber stamp instead of the contemporary fax-stamping that occurs with modern fax management systems.

"These are more examples of what's wrong with Medicare's procurement system for home medical equipment," said Tom Ryan, president of the American Association for Homecare. "The out of control audits, and documentation rules, as well as the bidding program, need to be fixed so that suppliers can concentrate on serving Medicare beneficiaries rather than worrying about when and how CMS is going to screw them next."

The American Association for Homecare represents providers of home medical or durable medical equipment and services who serve the needs of millions of Americans who require prescribed oxygen therapy, wheelchairs, enteral feeding, and other medical equipment, services, and supplies at home. Visit www.aahomecare.org.